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Summary of the impact

Research carried out by LSHTM into mental disorders in low- and
middle-income countries has
promoted new approaches to mental health care and influenced donors,
practitioners and policy-makers,
contributing to changing global priorities in this area. WHO launched a
flagship action plan
based on the research, governments and NGOs made substantial financial
allocations for
implementing the research innovations, and the findings have been
translated into treatment
guidelines used to train health workers in managing mental illness in many
countries.

Underpinning research

Mental health problems make a substantial contribution to the global
burden of disease. In low-and
middle-income countries, more than 20% of all disability related to health
conditions is caused
by mental health problems. It is on these pressing issues that Professor
Vikram Patel, who joined
the LSHTM in 2000 (then Senior Lecturer), has focused his research. The
research was carried out
between 2000 and 2012 in collaboration with many LSHTM colleagues who have
mental health
expertise, and especially Alex Cohen (LSHTM from 2008 as Senior Lecturer),
Mary De Silva
(LSHTM from 2005, then Research Fellow, now Senior Lecturer) and Professor
Betty Kirkwood
(LSHTM from 1979, then Lecturer). Since 2009, they have been functioning
under the umbrella of
the Centre for Global Mental Health (CGMH) in partnership with King's
College London.

The research fell into three areas:

Evidence of the burden of mental health problems in low- and
middle-income countries.
Projects included the first systematic review of the burden of, and cost
effective treatments for,
mental disorders (along with other noncommunicable diseases — NCDs)3.1
and the first
nationally representative survey of suicide mortality in India in 2010.3.2
Other research included
population-based surveys carried out in 60 countries in 2006, examining
the association of
depression with other chronic conditions; identification of close
association of mental health
issues with maternal and child health and chronic physical health
conditions (e.g. a cohort
study demonstrating the impact of maternal depression on infant growth
in India 1998-2000);
and examination of the vicious cycle of disadvantage, social exclusion
and mental health
problems (e.g. a study of young women in five Indian states, 2002-2003).

Demonstrating that evidence-based treatments can be delivered in
low-resource settings by
non-specialist health care workers.3.3 Research projects
included the Manas cluster
randomised controlled trial, the largest trial in psychiatry in the
developing world, in India
(2007-2009),3.4 which tested the effectiveness of an
intervention led by lay health counsellors
for people with depression and anxiety disorders, and the first trial
for supporting caregivers of
people with dementia in the developing world, also in India (2003).

Demonstrating the great paucity and inequitable distribution of global
mental health research
resources and outputs (e.g. via a survey of researchers from 52
countries in the developing
world, 2004-2005). This led to efforts to set the priority agenda for
mental health research,
policy and practice in the global context (e.g. through a global Delphi
priority-setting research
initiative involving 422 mental health stakeholders around the world,
2010-2011).3.5 This body
of evidence also formed the basis of a pivotal six-article Lancet
series and a call to action led
by Patel on global mental health.3.6 Its publication was a
key event in the emerging field of
global mental health and was followed by several other high-profile
series, including two in
PLoS Medicine (2009, 2012) and another in The Lancet
(2011), both led by Patel.

• Patel, A Community Cohort Study of the Relationship Between
Gynaecological Morbidity and
Common Mental Disorders in Goa, India, Wellcome Trust Career Development
Fellowship in
Clinical Tropical Medicine (UK), 10/2000-9/2005, £760,190.

Details of the impact

LSHTM's research has played a key role in promoting new approaches to
mental health care and
influencing policy-makers and donors, in the following ways.

Informing global and national policies for improving access to mental
disorders. In 2008, WHO
launched a flagship action plan to scale-up services for mental
disorders (mhGAP). This
referenced The Lancet mental health series in which Patel played
a leading role.5.1 This
subsequently led to a WHO resolution for a Comprehensive Mental Health
Action Plan approved
by the World Health Assembly in 2013. In 2011, the Ministry of Health in
India set up a mental
health policy group, including Patel, to write India's first mental
health policy and make
recommendations for the scaling-up of mental health care. For example,
Patel's research was
extensively cited in the XIIth Plan District Mental Health Programme
which is now being rolled
out throughout the country.5.2

Enabling the launch of global civil society partnerships to advocate
for mental health. In October
2008, the Movement for Global Mental Health was launched in direct
response to LSHTM's
research and Patel's call to action.5.3 The Movement, a
coalition of individuals and institutions
aiming to improve services for people with mental disorders worldwide,
now has over 3,000
individual and 150 institutional members from over 100 countries.

Increased resources for global mental health. Grand Challenges Canada5.4
has committed
C$30m for innovations which address the Grand Challenges in Global
Mental Health and the
funding of a Global Mental Health Platform (led by LSHTM) to disseminate
innovations to the
wider communities of policy-makers, practitioners and civil society
stakeholders. The US
National Institute of Mental Health (NIMH) has also committed over
US$15m to fund five hubs in
developing countries involving partnerships between researchers, policy
makers and civil society
to implement these Challenges (LSHTM is the lead institution for one of
the hubs). Both
reference papers co-authored by Patel.

Informing the mental health programmes of development agencies and
NGOs. Various
international agencies have cited the research of LSHTM as justification
to initiate and expand
their own mental health care programmes. For example, the World
Federation for Mental Health
(the world's largest mental health NGO) has aligned its global programme
to be consistent with
the research evidence generated by LSHTM and the call to action.5.5

Providing practical tools for mental health care in the field: (i)
Patel's manual, Where There is No
Psychiatrist, published in 2003 and providing practical guidance,
has been translated into more
than a dozen languages. Since 2010, the manual has been core reading for
a new mental health
nursing training programme in Liberia, and has been used by over 4,000
village doctors in
Bangladesh since 2008. It is the core mental health manual for MSF
programme staff.5.6 In 2008
permission was given to reproduce the manual as 25,000 CD-ROMs, produced
by WHO and the
Inter-Agency Standing Committee (IASC) and disseminated to agencies
working in emergency
situations. The message of the value of lay health workers in mental
illness care has been taken
to a wide public audience, for example through a TED talk by Patel5.7
which by end July 2013
has had 353,047 hits. (ii) A specially appointed WHO guideline
development group, including
Patel, developed guidelines5.8 based in part on LSHTM's
research for the management of mental
disorders. Since its launch in October 2010, the resulting mhGAP Intervention
Guide has been
rolled out in Ethiopia, Jordan, Nigeria and Panama, and used in
humanitarian settings in Haiti,
Equatorial Guinea, Palestine, Syria and Lebanon.

Establishing global mental health as a discipline for study and
practice. The research has
prompted several leading international universities to set up teaching
programmes in global
mental health (e.g. Duke, Harvard, New York University). Patel has led
or been actively involved
in the establishment of Centres for Public Mental Health in South Africa
(at the Universities of
Cape Town/Stellenbosch) and India (at the Public Health Foundation of
India where he directs
the new Centre for Mental Health).5.9 Patel's work has been
specifically cited by Arthur Kleinman,
one of the most influential thinkers in global mental health: `Medical
students who seem largely
uninterested in academic psychiatric research are flocking to ...
projects inspired by other
models of community care such as those initiated by Vikram Patel and
colleagues [seewww.sangath.com; www.centreforglobalmentalhealth.org].
Among many others, these
approaches appeal to those health professionals and students for whom
social justice and care
for the suffering of the poor are central, and have moral force.'5.10

5.8 WHO (2010) mhGAP Intervention Guide for Mental, Neurological and
Substance Use
Disorders in Non-Specialized Health Settings: Mental Health Gap Action
Programme (mhGAP).
Geneva: WHO, http://whqlibdoc.who.int/publications/2010/9789241548069_eng.pdf
(accessed 11
September 2013). Patel was a member of the WHO mhGAP Guideline Development
Group (p iv).